Get Letter Of Interest Form - Beacon Health Strategies

Filling out the Letter Of Interest Form - Beacon Health Strategies is an essential step for providers interested in joining their network. This guide provides a clear, step-by-step process to ensure users accurately complete the form online, with all necessary details included.

Follow the steps to successfully complete the Letter Of Interest Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by entering the Provider Name or Legal Entity Name as listed on the W-9 form. Ensure that this name matches your official tax records.
3. Fill in the Requesting Individual's name if it is different from the Provider Name. This helps identify who is submitting the form.
4. Input the date of the application to indicate when the form is filled out.
5. List all Licensures, such as LICSW, MD, or LMHC, ensuring that you include all relevant credentials.
6. Enter your Tax Identification Number (TIN) accurately, as this is critical for your application.
7. Include your National Provider Identifier (NPI) to identify your practice within the healthcare system.
8. Provide both your Practice Address and Mailing Address separately for clear communication.
9. Fill in your Phone Number and Fax Number to allow for easy contact.
10. List your Medicare Number and Medicaid Number, if applicable, to denote your eligibility for those programs.
11. Indicate the languages you speak that may assist clients with limited English proficiency.
12. Detail your Availability by specifying the hours you are accessible, and remember to include any evening and weekend hours.
13. Note the Years of Experience in Private Practice to highlight your professional background.
14. Provide a Description of Services, being specific about the types of services you offer, such as inpatient or home-based services.
15. Ensure you have included all requirements related to Service Availability and Hours of Operation, including any notable conditions about crisis intervention services.
16. Attach the completed W-9 form, as it is required for consideration in the application process.
17. After completing all sections of the form, review all information for accuracy. Once confirmed, you can save changes, download, print, or share the form as required.

Start filling out the Letter Of Interest Form online today to take the first step in connecting with Beacon Health Strategies.